Tuesday, December 29, 2009

Despite the lack of updates over the weekend, I was still at work. I have two weeks of vacation coming up starting a week from Friday, but it's straight through until then-- New Years Eve, New Years Day, etc. Being in the private hospital for the past few weeks instead of the public hospital has caused a few observations:

1. People with insurance feel entitled to make unreasonable demands. I've had a number of patients' families demand the patient be discharged at a certain time of day because it's most convenient for them. It's one thing if that time of day is "before 5" or "in the afternoon" -- it's quite another to be told that there's a one-hour window from 3-4 when they will be "able to accept him." Or one who demanded the patient be discharged before 7AM so she can get to work. We're not a concierge service. There are tests that need to be run, discharge summaries to write, doctors who need to sign off on things. The process takes time. Just because you have insurance doesn't mean you can dictate my schedule.

2. Similarly, two patients have threatened to "write letters" to the hospital CEO complaining about their care. One was complaining that the food wasn't any good, and the other was complaining there was nothing good on the television. Again, we are a hospital, not a hotel. If you are well enough to complain about the food or the cable, you should leave. Also, they should know that the CEO really won't care about their letters.

3. At the public hospital, patients are very deferential -- I'm always called doctor, and even the drug addicts and alcoholics seem to respect that we're professionals, even if they're belligerent and don't want to listen. At the private hospital, I've repeatedly been called by my first name, asked by families to "clean the bathroom better," and told that I don't know what I'm talking about because of something they read on the Internet.

As I write this post, I'm realizing-- it actually hasn't been the patients doing any of this, almost entirely. It's the families. The families of people with insurance think this is a hotel, not a hospital. And it makes the job much more difficult, because I have to deal with them.

No more complaining in 2010-- that's the resolution-- so I need to get it all out now.

Friday, December 25, 2009

Not a surprise: it is sad to work on Christmas.

It's hard to feel too sorry for yourself when surrounded by sick people, but the entire hospital today was filled with doctors and nurses who didn't want to be there, and it was really hard not to get drawn in to the self-pity. "First time I haven't spent Christmas with my family," "I'm going to have Christmas dinner all alone," etc. I'm a huge downer about almost everything-- and the neverending crush of six days a week, 12+ hours a day is terrible, absolutely-- but it is what it is. For the next three years, we work holidays. Someone has to. People still get sick.

Although not that many people.

It's hard not to start questioning how necessary most hospital visits are when on Christmas Day we got about a fifth of the usual headcount. If 80% of the people usually coming to the hospital don't come if it's Christmas, why are they coming when it isn't Christmas? I don't think there are fewer people getting sick today, or fewer people having accidents. So most of them are just choosing not to come. Why can't they choose not to come every day? And then I could get home at a normal hour.

We had a stupid ethical dilemma today-- for some reason, the orders got mixed up, and a patient ended up getting a doppler of her leg when there was no reason to do it. And the scan showed she has a clot. She also has a history of bleeding, so treating a clot has potential complications, and may also interfere with our treatment of what she's actually in the hospital for.

So the resident's first inclination was to pretend we didn't see the scan. The scan was never ordered, it shouldn't have been done, there was no medical reason to do it, and if it hadn't been done, we would have never known about the clot. .....

Except of course that's not really in the best interests of the patient (even though it's easier) and we can't put the genie back in the bottle. We know she has a clot, we have to figure out a way to treat it, and balance all of the patient's issues as best as we can.

The resident realized we couldn't just ignore it, called the attending, and even though it took an extra hour, we figured out what to do.

If the clot was going to cause a pulmonary embolism, then this accidental scan very well could have saved the patient's life. This should scare you, as a potential patient. A life possibly saved, by a scan that no one ordered, that just happened to accidentally get done. Perhaps appropriate on Christmas-- perhaps this patient's Christmas miracle.

Not to get too caught up in fate and a higher power. But, really, it's almost enough to be okay with having to work on Christmas.

Thursday, December 24, 2009

Sometimes the family members provide even better stories than the patients.

My attending told us a story. He goes into one patient's room to tell his wife that visiting hours are over and unfortunately she needs to leave for the night. They're very old-- they've both got some degree of dementia, neither one is in very good shape. She's sitting at the bedside, stroking the patient's leg.

"I don't want to leave," she says. "My husband needs me, he gets very anxious when I'm not here, I need to calm him down, won't you please let me stay?" as she continues to stroke his leg.

Monday, December 21, 2009

During rounds this morning, we were dealing with a patient with a grossly enlarged testicle, and the attending puts his stethoscope right on the thing, no sterile cover or anything. Next room, elderly woman, he puts the stethoscope right on her chest. Didn't clean it in between or anything.

I wanted to say something. Something like, "doctor, did you wipe that down?" but it's so hard to question anyone. It's different for something major-- I was reading one of the notes that an attending wrote on my patient, and noticed he didn't mention the potassium level, which had come back crazy high in the lab work. So I called him to make sure he saw that, and it turned out he hadn't, and we had to add a couple more pills into the mix. But in real-time, in person, it's hard to question an attending, especially when it's "just" about cleanliness and not about medication levels or something that you know is definitely going to mess up the patient.

But it gnawed at me for a couple of minutes, so I said something afterwards, phrased it like a question I didn't already know the answer to-- like, "I notice some docs are super-vigilant about the stethoscope, but it varies-- is it overkill to be cleaning it between each patient, or should we try and remember to do that, every time?" And he said, yeah, we should probably do that every time, but he forgets sometimes, and it's bad form. And he cleaned it before the next one. And then forgot before the one after that.

Even though it's been almost six months of this, it's still hard to wrap my head around how thin the line is between 'patient gets good treatment' and 'something goes wrong'. The rotation I'm on right now, there's a systems problem-- it's all private attendings, they see the patients, they write their notes, but there's no central coordination of anything. It's up to me and my resident to keep track of the notes, and to keep track of the overall patient management, but we don't actually make any decisions, and we don't always know who has seen the patient, if they don't write the note right away. We have a guy who's being seen by a couple of different specialists, and they keep entering conflicting orders-- give drug X, says one of them. Stop drug X, says the next. Next day, same thing-- give drug X, stop drug X. They don't talk to each other, and when we call to resolve the conflict, they're both happy to defer to the other one-- but we haven't yet resolved it. We gave it one day, we didn't give it the next, we don't know which doctor is right and neither do they.

Friday, December 18, 2009

I'm talking to a patient in his room when his cell phone rings. He puts his hand up for me to stop talking and takes the call. "Hello?" he says. "Yeah, yeah, what do you want? I'm talking to the male nurse." He has a thirty-second conversation and then hangs up.

"Sir, I'm actually a doctor, not a nurse."

"I thought the other guy was the doctor."

"Yeah, we're both doctors."

"It seems like you do all the nurse stuff."

Four years of medical school, for this? I'm wearing a white coat. I have a stethoscope. What more can I do to look like the doctor?

My attending got a little annoyed at me today. A patient's brother asked why we'd stopped doing a certain treatment on the patient, and I said the attending decided it wasn't necessary. The brother wanted to know why, and saw the attending standing right outside the door-- so he went over and asked him.

The attending pulls me aside afterwards-- "why did you send that family member after me?"

"I didn't-- he was just asking--"

"Don't tell these people any more than you have to. They don't need to know our decision-making process. All they need to know is we're doing everything we can for the patient. I don't want anyone questioning what we're doing--"

"He asked specifically about that treatment--"

"And you tell him it's no longer the right treatment and you leave it at that. You don't say I decided something, or anyone decided anything. It's no longer the treatment. That's it. No questions. It's not our job to explain ourselves."

I mean, this guy is a good attending, and I think he's sort of right-- we don't want to explain every decision to every family member-- but when asked a real question I think they're entitled to a real answer, and to know what's going on. Even if it takes thirty seconds out of our day.

But I'm sure I will soon be jaded and sick of talking to family members and want to do everything I can to brush them off, like a real doctor.

Another patient, showed up to clinic. I look at his chart and see that last time he came in because he was bleeding from his penis whenever he ejaculated, which made me very excited to find out what was bringing him back here.

"I have a stuffed nose, doc."

"That's it?"

"Yep."

"Okay, great. How long has it been feeling stuffed?"

"Four or five years."

"Do you think it might be allergies."

"Oh, I was on allergy medication for a while, but I stopped it recently, and my nose became stuffed again. So I don't think it's that."

"I'm sorry, run your logic by me again?"

"I took the allergy medication, but when I stopped taking it, my nose became stuffed again. So it didn't fix anything-- it must not be allergies."

"No, the medication doesn't cure allergies, it just treats them. So when you stop taking it, the allergies come back."

"Then what's the point of the medication if it doesn't do anything?"

"It takes the allergy symptoms away, as long as you take the medication. It works as long as you continue taking it."

"So I have to take it forever?"

"As long as you want the symptoms to go away, I'm afraid you do."

"That's ridiculous."

"I'm sorry, sir. That's how the medication works."

"You mean that's how it doesn't work."

"If you want to think of it that way, I'm not going to argue with you."

Monday, December 14, 2009

I'm getting sick. Which sucks for me, and sucks for my patients, since I'm not sick enough that anyone's going to actually want me to stay home, but I'm totally sick enough that I feel like I'm sleepwalking through the day. I don't think it's anything real-- right now I'm just a little sniffly and there's a little scratchiness in my throat-- but it's still hard to be "on" for 12 hours in a row when all I want to do is lie down and take a nap.

Today was my first day of the new rotation, which is a relief because if I had to spend one more day where I was, I think I was going to jump out the window. On Friday I was at the hospital until midnight, and it wasn't much better on Saturday. We had one patient who came out of surgery and started acting psychotic. We didn't know what was going on, ran a whole battery of tests, called in the attending, thought he was having a reaction to something, that maybe something serious was going on... and then he had a moment of lucidity and told us he forgot to mention he was on a couple of medications that we didn't know about and hadn't given him... and so this was just withdrawal from those. Awesome. When you're in the hospital, please tell your doctors all the medicine you take and not just some of it. Otherwise we think we've done something wrong when really you're just a moron.

The new rotation seems better. Different hospital-- private instead of public; my first time doing a rotation at this one. There's a big difference as far as the nursing staff. It's really quite crazy. I didn't realize there would be such a difference, but these nurses actually know things, and actually do things. One of them entered the patients' overnight lab results before I got in-- I was floored. They know what lab results are? They know how to use the computer system? Incredible. Not to disparage the nurses at the other hospital, because, hey, they've probably just never been told to do any of this stuff, and are short-staffed and some of them work hard, but it's night and day. They actually hire enough nurses here, with enough training and education, that they seem truly helpful. Maybe I'll be able to go a whole month without having to collect any urine samples on my own. I can dream, can't I?

Thursday, December 10, 2009

Another late night.

I don't know why the hours this month have been so much longer than previously. The job isn't any different. I think the whole team, on any particular rotation, is forced to operate however the resident operates. If he doesn't mind staying late, everything is going to happen later in the day and everyone's going to be stuck there. If he wants to leave early, he'll push everyone to get their work done, and everyone will get to leave. The problem is when there's a mismatch between how many hours the intern wants to work and how many hours the resident doesn't mind being there.

It makes me feel like I'm lazy. It makes me feel like this is the wrong career for me. Everyone else wants to be here, it seems. They check in from home. They think about the patients after they leave. They want to follow up. They're interested in what's going on. They genuinely don't mind spending every waking hour in the hospital.

I'm not like that, and I don't know why. It's not as if I have anything waiting for me at home, I just don't want to spend 15 hours at work. I'm not interested in the patients, honestly. Someone comes in and my first thought isn't about how I can make him better, it's about whether he's going to make me stay even later. Test results come back and I want them to be normal not because I want the patient to be okay but because I don't want to have to do anything. I want patients to leave. Someone tells me my patient died, I think, great, one less patient. I don't care. If it was a member of my family, I would care. If it was a friend, I would care. If it's someone who's dying anyway, I don't know that I care.

Okay, I'm a broken record this week. Something lighter. I had to extract a stool sample from a patient today. My co-intern came along to watch (!!). No, I don't know why she wanted to watch. She said to me, "you don't seem to like doing procedures." No, I don't! I don't want to get dirty. I don't want to use my hands. This is why I want to do primary care and not surgery. I don't want to extract stool. I don't want to see stool. I don't want to touch the insides of anyone.

...and that is why I'm going to make no money. Because insurance pays for procedures, and I don't want to do any. I just want to chat with my patients, get to know their life stories, and pass them along to a specialist who can extract their stool instead of me.

Tuesday, December 8, 2009

Yesterday was my latest night at the hospital since I've been on the day shift. I got there at 6:45 and didn't step out the door until 10:33 at night. (And back before 7 this morning.) I am so happy this rotation will be over this weekend. Not that there's any reason to think the next one will be any better-- and in fact I've heard it's worse-- but somehow the combination of this hospital and my patients and my team and these nurses has just made the whole thing so much harder than it should be.

What kept me so late was a patient with a fever, and an overworked nursing staff that is poorly synchronized with the doctor shifts. The nurses shouldn't have their shift handoffs an hour after the doctors do, it just shouldn't work that way. We're allowed to start handing patients over to the night team at 6, and the nurses change shifts at 7. In theory, I understand why this is supposed to work-- if the doctors are all ready to make their shift change at 6, then the night team is already set up with the patients by the time the nurses change, and there shouldn't be a lag. But, for the most part, the doctors are never really ready at 6. If nothing's going wrong, we're done at 6. But if anything's happening with any of our patients, we can't sign out, we have to do whatever we need to do to get the patient stable, run whatever tests, wait for whatever results, start whatever new medications.

So at 6:00, as I'm hoping to get to sign out, we realize my patient has a fever, and I need to order a urinalysis. I ask the nurse. She says she has other things she has to do before her shift is done, and she won't do it. I had an admission to deal with, so I figured I would just wait until 7 and grab the new nurse. By the time I find her at 7:15, she's already been given a list of half a dozen things to do, and says she'll get to the urinalysis when she can. At this point, I figured I'd just do it myself. Except we discovered the patient was incontinent and urinating all over herself. We needed to put in a catheter. I've never done this on my own. I waited for another intern to be free enough to help. We put in the catheter. I got the urine sample. It's 9:00 at this point. I bring it to the lab. And of course by 9:00 everything is working in slow-motion. I wait an hour for them to "rush" the results. And by the time I then do what I need to do and sign out, it's after 10.

I understand why we have to wait for test results, and can't just sign it over to the night team, I guess. I mean, I was on nights, I know what it's like to have 75 patients under your care and how annoying it is when a doctor leaves you someone who needs follow-up. It's enough that you have to deal with the emergencies that come up, but to have patients who you already know are going to take your attention, it makes it too much for the night person to have to deal with. But then there should be extra support at the transition period -- there should be an overlap so nurses can help get things done and help get the day doctors out at a normal time. Or the shift shouldn't end at that point, it should end two hours earlier, so the new nurses have time to get situated before the rush that needs to happen to get the day team out of there.

I don't know why I'm trying to explain this, and why I'm fixated on this systemic problem. I'm just grumpy that I had to be there so late, and I want to believe there's a way to fix it instead of being forced to admit that, hey, these are sick people and sometimes things happen, and for the next two and a half years there are going to be weeks like this, there are going to be nights I'm there for hours, trying to get someone's urine in a container so I can take it to the lab.

I ran into the attending from a previous rotation, and he told me one of my patients just died. Is it wrong that I don't feel too sad about it? This patient treated everyone poorly, treated his family poorly, and basically drank himself to death. Has this job made me so jaded that I feel nothing for him? That I'm not fazed in the least? I hope I'm still human. Gosh, this week sucks.

Wednesday, December 2, 2009

Better today. It's weird, in the moment I feel like there are all these ups and downs, but really there shouldn't be. Each day is more or less the same, and whether I leave at 6:45 or 7:15 shouldn't mean the difference between feeling good and feeling awful. I have bad days, the people around me have bad days, but all in all it's okay. My resident isn't so terrible, I like most of the people I'm working with, my patients are not suffering at my hands, the days are long but it's okay.

Deep breath.

I did my first procedure yesterday. Drained some fluid from a patient's abdomen. He said I did good. Nevermind that he didn't really know what was going on and what I was doing to him. Felt good to feel competent at a procedure. I can do things, sometimes. If I was alone in the hospital, if I had no one to ask, no one to teach me, I could at least muddle through some simple things and not kill my patients. That's a nice feeling, I guess. Makes me feel like one day I might be okay at this. In clinic, I saw 5 patients in an afternoon, which is the most I've gotten through so far. The attendings see 10 or 12 in an afternoon, but 5 isn't bad. Two patients asked for my card (as if I have one...), asked if I was new, asked if I can be their doctor next time they come. So that was nice.

And this morning, no new overnight admissions. Maybe it'll be a short day. Maybe it won't be. I don't know. No one knows. I treated myself to a $6.00 piece of pumpkin pie on the way home last night, from a bakery that's too expensive and not as it good as it thinks it is. Little things. Little moments. I'm trying.